Health inspection·August 22, 2025

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few tracks the administration of treatments and medications to patients) reflected the resident's catheter had not been changed. Record review of Resident #1's progress note documented by the NP reflected the following: .08/04/25 Seen at request of staff d/t AMS [a disruption in how the brain works that causes a change in behavior]. Pt is acting paranoid, thinks his food is being contaminated. Says his penis is swollen and tender.1. Altered mental status, unspecified altered mental status type STAT CBC [a blood test that measures the amounts and sizes of your red blood cells, hemoglobin, white blood cells, and platelets], BMP [a blood test that measures eight different substances in the blood], UA [a blood test that analyzes urine].await results .2. Swollen PenisSwitch out catheterGentle pericare [hygiene practice involving cleansing of the genital and anal area]Monitor closely. Record review of Resident #1's progress noted dated 08/04/25 documented by RN A reflected the following: This nurse received a new order for CBC, BMP, and UA in [lab system] and to change the Foley catheter, immediately this nurse deflated the balloon, patient began to bleed. This nurse notified the [physician], ordered not to remove the catheter but inflate it and leave in place and monitor patient and call if bleeding continues. Informed the incoming nurse to follow up. Further review of Resident #1's progress notes dated 08/05/25 documented by LVN B reflected the following: Critical lab results received. MD on-call notified. New order received to send patient to the hospital for evaluation.911 called, patient transported to the ER at [hospital]. Patient in stable condition at the time of leaving the facility. Record review of Resident #1 lab results report dated 08/04/25 reflected the following: BMP Results Reference Range Potassium 6.4 mmol/L 3.5 - 5.1BUN 103 mg/dL 6 - 25Creatinine 6.01 mg/dL 0.70 - 1.30 Potassium - (high potassium levels occur when blood potassium is too high, often caused by kidney problems, certain medications, or severe illness) BUN - (Blood Urea Nitrogen test which measures a waste product in the blood to assess kidney function) Creatinine - (a waste product from normal muscle breakdown that healthy kidneys filter from the blood and excrete in urine and measures this waste product to assess kidney function) Record review of Resident #1's hospital records dated 08/05/25 reflected the following: Assessment and Plan(Principal) Hyperkalemia [high potassium]Acute kidney injury.Gross hematuria [visible blood in the urine, making it appear pink, red, or brown] Due to Foley trauma. Balloon was noted to be in urethra. Catheter was removed. NP reports significant bleeding after catheter removed. Foley was reinserted. Patient with continued gross hematuria. No urology is available at this facility. House supervisor asked to assist with transfer to a higher level of care for urology evaluation. Hospital Labs Potassium - 5.9BUN - 94Creatinine - 4.88 Interview on 08/20/25 at 1:46 PM with RN A revealed during her shift on 08/04/25, Resident #1 refused his medications and refused to eat. She stated this was not Resident #1's baseline. She stated the NP happened to be doing her rounds that day, so she asked the NP to assess the resident. RN A said the NP ordered blood work and a UA to be done via straight catheterization. RN A said the Treatment Nurse was in the room when she (RN A) was going to remove Resident #1's catheter. RN A stated when she deflated the resident's catheter balloon, fresh blood came out on the drape under the resident and appeared to be mixed with urine. At that time, RN A said she stopped, left the catheter in place, and called the physician. The physician gave orders to leave the catheter in place, reinflate the catheter balloon, and monitor for further bleeding. RN A stated when she re-inflated the catheter balloon she did not feel resistance and the bleeding stopped. During the procedure, she said she did not notice any redness or swelling to Resident #1's penis. RN A further stated it was the end of her shift, and Resident #1's bloodwork results had not come back during her shift. She stated Resident #1 did not have issues with his catheter prior to that day. RN A said she had been trained on the insertion and removal of Foley catheters, but she did not give a date of the training. Interview on 08/20/25 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 2 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 2:40 PM with the Treatment Nurse revealed RN A got orders to change out Resident #1's catheter on 08/04/25, and she went in to assist. The Treatment Nurse said RN A deflated the catheter balloon and pulled out 10 cc of fluid via syringe. She stated blood began to come out from around the catheter on to the drape under the resident. The Treatment Nurse said she told RN A not to pull the catheter out and to leave it in place because the blood could indicate possible urethral trauma. The Treatment Nurse said RN A immediately called the physician and the physician gave orders to leave the catheter in place and re-inflate the balloon. The Treatment Nurse said there did not appear to be any resistance when RN A reinflated the balloon, and Resident #1 did not appear to be in any distress. The Treatment Nurse stated Resident #1 had urine in his bag after the attempted catheter removal. The Treatment Nurse stated she did not recall the resident having any issues with his catheter prior to that day they tried to change it. Interview on 08/20/25 at 3:57 PM with LVN B revealed he worked the night shift of 08/04/25 and Resident #1 had not been eating. He stated Resident #1 reported feeling tired which was not Resident #1's normal baseline. LVN B said he was given report to monitor the resident but had not been told blood had come out during an attempted catheter change. During his shift, he stated Resident #1's bloodwork results came back with some critical labs. He stated the physician was consulted and gave orders for Resident #1 to be sent to the hospital for further evaluation. When Resident #1 was sent to the hospital, the resident's vitals were within normal range. Prior to 08/04/05, LVN B stated Resident #1 had not had any catheter-related issues. Interview on 08/21/25 at 2:27 PM with CNA C revealed she had worked with Resident #1 around the time he had been sent to the hospital (08/05/25), but did not recall which day. CNA C said she provided care to the resident and noticed his penis was swollen, and there was blood coming from his penis around the catheter line, which she reported to LVN D. She stated LVN D was already aware of the resident's condition, and LVN D was checking on the resident. CNA C stated Resident #1 complained about discomfort to this catheter, and the resident wanted to make sure someone was checking on him during her shift. Interview on 08/21/25 at 2:35 PM with CNA E revealed she worked with Resident #1 the day he was sent to the hospital on [DATE] during the morning shift (6:00 AM to 2:00 PM), and had given the resident a bed bath. CNA E said when she changed the resident, she noticed his penis was swollen and had some dried drainage around his penis. CNA E said Resident #1 did not express he was in pain or discomfort. CNA A said she reported the drainage to RN A, who went to assess Resident #1. She stated later she saw the NP go into the resident's room. Interview on 08/21/25 at 3:16 PM with LVN D revealed he worked with Resident #1 on 08/04/25 during the 2:00 PM to 10:00 PM shift. He stated RN A reported to him that the NP ordered a UA and for Resident #1's catheter to be changed. RN A told LVN D she and another nurse (Treatment Nurse) tried to change the resident's catheter but when they had deflated the balloon and before they pulled the catheter out, blood was noted to be coming out from around the catheter. LVN D said RN A told him she had contacted the physician and he had given the orders to leave the catheter in and monitor. LVN D said he went in to see Resident #1 after getting report and there was some blood around the tip of the resident's penis, the collection bag had some urine in it but he did not see any blood in the bag. LVN D stated he did not notice any swelling to the resident's penis and there was nothing out of the ordinary during the resident of shift and the resident continued to have urine output in the bag with no blood in it. LVN D further stated Resident #1 did not have any issues with his catheter in the past. Interview on 08/21/25 at 3:45 PM with Resident #1 revealed, during his bed bath on 08/04/25, one of the aides (CNA E) told him his penis was infected and looked like it had some kind of drainage/puss to the area. The resident said the NP went in to see him and told the nurse his catheter needed to be changed. The Treatment Nurse assisted RN A and during the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 3 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few process, he stated he felt some pain, and it appeared something went wrong because it bled. Resident #1 said, sometime later, he was sent to the hospital, and the staff there told him something had ruptured in his urethra when they tried to change the catheter. Interview on 08/21/25 at 12:45 PM with the DON revealed the weekend of Saturday 08/02/25 and Sunday 08/03/25 Resident #1 did not want to eat and refused his medications. She stated RN A called her on Monday, 08/04/25 because said she and the Treatment Nurse tried to change the resident's catheter. RN A told her when they deflated the balloon, blood came out. RN A also told her the physician was called, and he gave orders to monitor the resident. The DON said they had ordered bloodwork and when those results came in, some of labs were critical so the resident was sent to the hospital. The DON further stated the nursing staff reported to her that Resident #1 continued to have urine output that afternoon before he was sent to the hospital. The DON said RN A had been trained on catheter insertion and removal upon hire and the training was a part of the Infection Control section. Record review of RN A's new hire training dated 09/16/25 reflected she took the Infection Control Portion. There were no other details to the training. Interview on 08/21/25 at 4:07 PM with the NP revealed she assessed the resident on 08/04/25 after staff told her Resident #1 had been acting confused and paranoid. The NP said when she assessed the resident she noticed his penis was slightly swollen so she ordered blood work, (CBC and CMP), a UA and a catheter change in case he had developed an infection (UTI). The NP said the resident's vitals were stable at the time, there was no bleeding to catheter site at the time, and there was yellow urine in the catheter bag. The NP stated she was not certain how the catheter balloon had gotten in Resident #1's urethra unless the catheter was tugged causing it to go into the urethra. Interview on 08/21/25 at 10:40 AM with the Physician revealed he cared for Resident #1, and there had not been any issues with the resident's catheter other than a couple UTIs. The last time the Physician had seen Resident #1 was on 07/30/25 for medication adjustments, and there were no issues with the resident's catheter. The Physician said, according to Resident #1's progress notes, Resident #1 had been seen by the NP on 08/04/25. He stated the NP documented that Resident #1's catheter was to be switched out because his penis was swollen. The Physician read Resident #1's hospital records and they said if it was documented that his catheter balloon was inflated in the urethra then it probably was causing bleeding from the trauma it caused the urethra. If the balloon was indeed in the urethra, the Physician stated it would explain why his BUN and Creatinine labs were critical which would indicate the resident was in acute renal failure because it would block the urine from flowing causing it to go back up into the kidneys. The Physician continued to read Resident #1's hospital records and said it appeared once the catheter was replaced his labs (Potassium, BUN, and Creatinine) began to decrease. The Physician said if the catheter balloon was in the urethra it was possibly inflated wrong or it was tugged on which would cause trauma and bleeding. Record review of the facility's policy titled Indwelling Catheter-Male and Female (Insertion and Removal of) reviewed on 06/2006 reflected the following: PurposeTo provide continuous drainage of the urinary bladder; to prevent contact of urine with open areas on the body; to obtain accurate measurement of urinary output; to obtain a sterile specimen for diagnostic purposes; and to instill medication into the bladder. Insertion of Indwelling Catheter .Procedure - .advance catheter one to one and one-half inches beyond the point of free flow or urine. - Check size of balloon; draw up sterile water to his amount (if not using pre-filled syringe), attach the syringe to the balloon port of the catheter. - Do not force water into balloon. If resistance is encountered or the patient complains of pain, deflated balloon, advance farther into the bladder and inflated. - Tug gently on catheter until you feel resistance. Removal of Indwelling Catheter.Procedure- Attach syringe to balloon port of catheter and aspirate entire amount of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 4 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few sterile water in balloon.- Pinch catheter and withdraw gently and slowly. Record review of the facility's policy titled Catheter Care, Urinary revised on September 2014 reflected the following: .Complications1. Observe the resident for complications associated with urinary catheters.b. Check the urine for unusual appearance (i.e., color, blood, etc.)c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidently removed. d. Report any complaints the resident may have of burning, tenderness, or pain in the urethral area. An Immediate Jeopardy was identified on 08/21/25. The Administrator, DON and the Regional Nurse Consultant were notified of the Immediate Jeopardy on 08/21/25 at 4:55 PM. The IJ template was provided to the facility on [DATE] at 5:10 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 08/22/25 at 8:30 AM and reflected the following: Concern:F684J - Quality of Care F684 The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person -entered care plan, and the residents' choices based upon the comprehensive assessment of a resident. On 08/04/25, a [AGE] year-old male resident, who had a diagnosis of quadriplegia and who had a urinary catheter, experienced a change in condition resulting in loss of appetite and tiredness. The facility notified the Nurse Practitioner about the change in condition, and orders were given perform a straight catheter to obtain a sample for a urinalysis and for blood work to be done. When the nurse deflated the catheter balloon to remove the urinary catheter, she noticed blood coming out around the catheter. The physician was immediately notified and instructed the nurse to re-inflate the balloon and monitor for further bleeding. A few hours after this the resident's lab results arrived and showed that the resident had critical labs. The physician gave orders for the resident to be sent to the hospital. At the hospital, the hospital discovered that the catheter balloon had been inflated in the urethra causing trauma and bleeding. The resident was transferred to a higher level of care for a urology consultation. The facility failed to properly insert a urinary catheter which resulted in the resident experiencing urethral trauma and bleeding. Immediate Actions Resident #1 is no longer in the building. The Medical Director was assigned this resident. 1 The Ombudsman was notified of the content of the immediate jeopardy via email on 08/21/2025. 2 On 08/21/2025 The RDCS in-serviced the DON and the Unit Managers with test for competency on: - Following physicians' orders - Effective Documentation Recognizing Changes in Condition - Urethral Catheter Placement with competency of test and with skill assessment checked off by nurse leadership/designee 3 On 08/21/2025 The RDCS and DON completed a 100% audit of all residents who are on catheters , who have the potential to be affected. The results of the audit yielded that no other residents were affected and were at their normal baseline. The Foley catheters were all appropriately placed and draining appropriately. Staff Training and Education Mandatory Training: Starting 08/21/2025 All licensed and registered nursing staff will undergo mandatory training on proper urinary catheter insertion and re-insertion techniques, including recognizing complications and responding appropriately. Training will be conducted by the DON/Clinical Designee. Competency Assessment: Each licensed or registered nursing staff member will be required to demonstrate competency in catheter insertion and re-insertion through hands-on evaluations. Staff who fail to demonstrate competency will not be allowed to work or perform catheter-related procedures until retraining and reassessment are completed. 4 On 08/21/2025 initiation of all in-house licensed and registered nurses and were re-inserviced with a test to validate competency on: Following physicians' orders Effective Documentation Recognizing Changes in Condition Urethral Catheter Placement with competency of test and with skill assessment checked off by nurse leadership/designee Systematic Approach 1. On 08/21/2025 A QAPI meeting was held, in attendance were the Medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676249 If continuation sheet Page 5 of 6 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Carlyle at Stonebridge Park 170 Stonebridge Lane Southlake, TX 76092 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Director (via TEAMS), Executive Director, DON, and the Regional Director of Clinical Services. Policy and Procedures on Physician Notification, Documentation and Changes in Condition were reviewed and found to be sufficient and met state and federal requirements. QAPI discussed the components and the interventions of this plan of removal. 2. The facility will incorporate catheter-related procedures into its annual staff training program and QAPI initiatives to ensure ongoing compliance and resident safety. Monitoring 1 DON, UMs were educated on 08/21/25 in the daily process of: a. The DON and Unit manager(s) were educated by the RDCS on 08/21/25 and will use the Grand Rounds process and 24-hour Summary to identify any and all residents who were may have been admitted with or given orders to insert a urethral catheter to ensure appropriate placement and flow. This will occur daily for 2 weeks, weekly for 2 weeks and then monthly. On the weekends and holidays, the Nurse Supervisor/Designee will complete the audit/review. The DON/ Designee will monitor daily, M-F, on the weekends and holidays, the Nurse Supervisor/Designee will complete the review. The DON/Designee will monitor this process. ******Any staff who are not present to complete the in-service by 8/21/2025 will be required to complete the in-service at the start of their next shift before beginning work. New Hires, PRN and any agency staff will also be in-serviced prior to the start of their shift. The education will be conducted and monitored by the DON/Designee. Quality Assurance: Results of all monitoring by DON and Unit Manager shall be brought to the Quality Assessment and Assurance Committee for review and any committee recommendations will be acted upon. The DON will be responsible for bringing the results of the monitoring to the QA committee. Completion Date: 08/21/2025 Monitoring the facility's Plan of Removal included the following: Observation on 08/20/25 at 9:45 AM revealed Resident #1 was no longer at the facility. Record review of the In-service Training Report dated 08/21/25 reflected 12 charge nurses were educated on Foley insertion, verify placement, documentation, physician orders, change of condition, complete transfer form. Further review of the training revealed each charge nurse was given a competency test and a skills assessment checked off by nursing management. Interviews on 08/22/25 from 11:26 AM to 3:29 PM from nurses from various shifts were the DON, ADON, Treatment Nurse, RN A, LVN B, LVN D, LVN F, LVN G, LVN H, LVN I, LVN J, RN K, RN L, and LVN M. All staff were able to identify the following: - What type of documentation is required with resident that have Foleys; (i.e. color, odor, urine output, urine retention, discomfort to area and size of catheter and balloon inflation)- How to insert a catheter using sterile technique in males and females. (insert until there is urine return and go farther if resistance is felt) - What to do if they feel resistance when inflating the catheter balloon. - How to remove a catheter (pull the same amount of fluid that was inserted in the balloon, and gently pull out)- What to do if the is blood noted upon removal (do not remove and call the physician for orders)Each charge nurse had a competency test and skill assessment as part of their in-service. Review of the audits dated 08/21/25 revealed there were 5 residents with catheters and there were no issues identified with the resident's catheters. Observation on 08/22/25 of catheter care for Residents #2, #3, and #4 from 10:15 AM to 11:06 AM revealed appropriate technique was used, clear urine was flowing in the output bags, and there were no issued noted. There were no residents that required catheter insertion or changing. The Regional Nurse Consultant and DON were notified on 08/22/25 at 3:45 PM, the Immediate Jeopardy was removed. While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Event ID: Facility ID: 676249 If continuation sheet Page 6 of 6